Citation Nr: 9836249
Decision Date: 12/10/98 Archive Date: 12/15/98
DOCKET NO. 95-20 673A ) DATE
)
)
On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO) in
Des Moines, Iowa
THE ISSUES
Entitlement to an increased disability evaluation for Wolff-
Parkinson-White syndrome, currently rated as 10 percent
disabling.
Entitlement to a compensable disability evaluation for scars
of the right hand.
Entitlement to compensation, pursuant to 38 U.S.C.A. § 1151
(West 1991 & Supp. 1998) for nerve damage to the right hand.
REPRESENTATION
Appellant represented by: The American Legion
WITNESS AT HEARINGS ON APPEAL
The veteran
ATTORNEY FOR THE BOARD
Mark D. Chestnutt, Associate Counsel
INTRODUCTION
The veteran served on active duty from August 1964 to July
1968.
This appeal stems, in part, from a May 1995 rating decision
of the RO that granted VA disability compensation benefits
pursuant to 38 U.S.C.A. § 1151 for scars of the right hand,
evaluated as 0-percent disabling, resulting from VA
treatment, but denied compensation for claimed nerve damage
resulting from the same treatment. The veteran has appealed
the rating assigned to the scars as well as the denial of
service connection for nerve damage of the right hand.
This appeal also stems from a February 1997 rating decision
which granted entitlement to service connection for Wolff-
Parkinson-White syndrome, assigning a 10 percent evaluation.
The veteran has appealed the rating assigned to that
disability as well.
The Board of Veterans’ Appeals (Board) finds that additional
development is necessary with respect to the increased rating
claim for the veteran’s scars. This issue, therefore, will
be addressed in the REMAND portion of this decision. The
Board also finds that the rating of the veteran’s right hand
scars is medically intertwined with the claim for
compensation for nerve damage allegedly arising from the same
incident. Consideration of the latter issue, therefore, is
deferred.
During his May 1998 video hearing before the Board, the
veteran raised a claim of a total rating for compensation
purposes based on individual unemployability. Since this is
not in appellate status it is referred to the RO for
appropriate disposition.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends, in essence, that his Wolff-Parkinson-
White syndrome warrants a rating higher than the 10 percent
evaluation assigned. He maintains that the condition causes
frequent chest pain.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1998), has reviewed and considered
all of the evidence and material of record in the veteran’s
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the evidence supports granting
a disability evaluation of 30 percent for Wolff-Parkinson-
White syndrome.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
disposition of the issue considered in the body of the
veteran’s appeal has been obtained.
2. The veteran’s Wolff-Parkinson-White syndrome is currently
manifested by palpitations associated with shortness of
breath and chest pain. These symptoms may represent
supraventricular tachycardia, secondary to Wolff-Parkinson-
White syndrome.
3. The veteran experiences chest pain at least once per
week, and occasionally as frequently as two to three times
per day.
CONCLUSION OF LAW
The schedular criteria for a disability evaluation of 30
percent for Wolff-Parkinson-White syndrome are met. 38
U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.104,
Diagnostic Code 7099-7013 (1997); 62 Fed. Reg. 65,207-224
(1997) (codifying Diagnostic Code 7010).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Initially, the Board finds that the veteran’s claim for an
increased rating for Wolff-Parkinson-White syndrome is “well
grounded” within the meaning of 38 U.S.C.A. § 5107.
Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is
also satisfied that all relevant evidence has been properly
developed and that there is no further duty to assist in
order to comply with the duty to assist as mandated by 38
U.S.C.A. § 5107.
In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, and 4.42 and
Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the service
medical records and all other evidence of record pertaining
to the history of the disability in question have been
reviewed. Nothing in the historical record suggests that the
current evidence of record is not adequate for rating
purposes. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994)
(in evaluating a veteran’s disability, where entitlement to
compensation has already been established and an increase in
the disability rating is at issue, the present level of
disability is of primary concern).
I. Background
The service medical records reveal that in August 1966 the
veteran complained that he had had chest pain for two days.
It was stated that no pathology had been found.
The veteran was hospitalized by the VA in January-February
1969 for hypertension. An electrocardiogram revealed a
Wolff-Parkinson-White syndrome “bubble” only
intermittently, and nonspecific T-wave changes suggestive of
possible myocardial disease, drug effect and/or electrolyte
abnormality. An associated clinical record noted the
abnormal electrocardiogram and that the veteran had Wolff-
Parkinson-White syndrome, probably intermittent.
Service connection for hypertension was granted in an April
1969 rating decision.
The veteran was noted to have right upper quadrant tenderness
on deep palpation during an August 1970 VA hospitalization,
but no objective findings regarding this symptom were noted.
During a March 1971 VA hospitalization it was noted that no
cause had been found for the veteran’s vague right upper
quadrant tenderness that he had had for the past few years.
A December 1972 record from the veteran’s private treatment
physician, J. C. Carr, M.D., with Medical Associates,
indicates that the veteran complained of chest pain at that
time. The condition appeared to be muscular in etiology.
A May 1973 VA clinical treatment record indicates that the
veteran had right upper quadrant tenderness but that his
hypertension was asymptomatic. The veteran was examined by
the VA in June 1973 on complaints of having had chest pain in
the previous six months. He indicated that he would
experience this pain after taking a deep breath or after
moving a certain way. He reported having had some shortness
of breath. Objective cardiac evaluation was negative except
for his hypertensive vascular disease which was possibly due
to renal disease.
During a November 1979 VA examination the veteran complained
that about once per week he would have chest pain, and that
he had had one episode of numbness of the left arm and leg
and the left side of his neck,. An electrocardiogram was
essentially negative. The examiner opined that the tingling
in the left arm was possibly related to ischemia, but that
further workup was needed.
VA clinical records from July and October 1980 characterize
the veteran’s chest pain as atypical. A June 1981 VA
clinical record indicated that the veteran’s Wolff-Parkinson-
White syndrome was asymptomatic but that he was taking
Inderal® anyway.
The veteran was hospitalized at St. Joseph Community Hospital
in New Hampton, Iowa, in July 1981 with complaints of severe
chest pain. For the past two days he had been complaining of
shortness of breath, lack of appetite, and a squeezing
feeling in his chest which had not improved with
nitroglycerin. He responded very well to Valium®. The
diagnosis was chest pain, probably secondary to anxiety.
Clinical records from the veteran’s private physician, Garry
Cole, D.O., with Medical Associates, show that in September
1981 the veteran had a considerable amount of chest pain.
The veteran admitted to having stress at work. It was
recommended that he try to obtain other employment and try to
avoid this type of stress. In November 1981 he fainted and
fell down some stairs. In June 1982 he quit work because of
his chest pain. The pain was described as slight
sharp/aching in type, but with no heaviness or tightness.
The veteran was hospitalized in February 1982, on complaints
of “heaviness” in the mid-sternal area. This was
associated with moderate shortness of breath, but he denied
diaphoresis or radiation of the pain. He had never had pain
like this previously. He took one dose of nitroglycerin
which “relieved the pain a little”. He was admitted with
the presumptive diagnosis of coronary artery pain--crescendo
angina, versus possible early evolving myocardial infarction.
The impression was also of heavy cardiac-like chest pain. A
discharge summary notes a final diagnosis of “chest pain
with Wolff-Parkinson-White syndrome”.
A VA clinical record from April 1982 indicates that the
veteran’s Wolff-Parkinson-White syndrome was asymptomatic
until November, when he had a sudden syncope episode walking
down stairs in suddenly losing consciousness without warning.
It was noted that the veteran’s chest pain was very atypical
and the examiner doubted that it was cardiac in origin.
The veteran was hospitalized by the VA in May 1982. It was
noted that the previous multiple admissions had, in essence,
ruled out a myocardial infarction. The veteran had essential
hypertension and multiple laboratory abnormalities, not
associated with symptoms. Discharge diagnoses included
Wolff-Parkinson-White syndrome with supraventricular
tachycardia and probable syncope, as well as atypical chest
pain.
A July 1982 letter by the physician who treated the veteran
at the VA in May 1982 notes that the veteran’s Wolff-
Parkinson-White syndrome was a cardiac electrical abnormality
that in some cases causes abnormally fast heart rhythms
resulting in loss of consciousness. A test had shown, he
indicated, that the veteran had supraventricular tachycardia
(an abnormally rapid heart rhythm).
The veteran was provided a psychiatric examination by the VA
in January 1983, at which time it was reported that the
veteran’s Wolff-Parkinson-White syndrome had been giving him
a lot of chest pain and syncope over the last couple of
years.
Veteran was hospitalized at St. Francis hospital and
Waterloo, Iowa, in April 1983. He reported having two
attacks of chest pain per day. It was concluded that the
veteran appeared to have Prinzmetal’s angina.
A September 1983 letter from Garry Cole, D.O., indicates that
the veteran had not had a myocardial infarction but that the
veteran’s chest pain was similar to such pain. During a July
1984 VA examination the veteran indicated that his chest pain
had progressed over the past three years, up to two or three
times per day in frequency. He noted that it was worse in
hot weather. The pain would last anywhere from a couple of
minutes to one hour without precipitating factors. This was
relieved with rest and occasionally, but not always, with
subinguinal nitroglycerin.
The veteran was hospitalized by the VA from June to July
1987. His chest pain history was noted, but an
electrocardiogram revealed no evidence of Wolff-Parkinson-
White syndrome. The impressions included atypical chest pain
and Wolff-Parkinson-White syndrome, stable.
The veteran was examined by the VA in November 1989, at which
time he reported experiencing paroxysmal episodes of
palpitations lasting approximately 15 to 30 minutes. He did
not report an association between his chest pain and the
palpitations.
A September 1989 private medical record from Medical
Associates notes the veteran’s previous cardiac history, but
indicates that the veteran had chest wall pain versus
pleurisy.
An October 1989 record from Garry Cole, D.O., contains the
veteran’s report of having chest pain in the left upper area
which radiated to the left arm, neck and lateral chest wall.
The pain sometimes would last 20 minutes and then subside.
It still came several times during the day, and was a sharp
pain at times, but other times was more of a constant ache.
A February 1991 VA clinical record indicates that the
veteran’s atypical chest pain was not relieved by
nitroglycerin, and that he had bradycardia/tachycardia
episodes during which he did not have chest pain. An April
1991 VA clinical record indicates that the veteran’s chest
pain was felt to be non-cardiac.
A December 1991 VA cardiac catheterization revealed
essentially negative findings.
An October 1992 letter from David W. Kabel, M.D., reveals
that the veteran’s continued to have intermittent chest
pains, but that these were not typical of ischemic heart
disease.
The veteran was apparently hospitalized from February to
March 1993 at St. Joseph Community Hospital. The pertinent
records indicate that the veteran’s chest pain was of an
undetermined etiology, and that his [electro]cardiograms were
normal.
During a May 1994 VA hospitalization the veteran’s chest pain
improved with subinguinal nitroglycerin.
A July 1995 clinical record from St. Joseph Community
Hospital indicates that the veteran was heparinized. Given
his response to nitroglycerin and heparin, he was admitted
for observation and to rule out a myocardial infarction. The
veteran’s chest wall pain was thought to be related,
probably, to stress. Angina could not be ruled out, however.
A June 1996 evaluation by a private physician, Prasad R.
Palakurthy, M.D., noted the veteran’s history of irregular
heart rhythm and palpitations. It was stated that these may
represent supraventricular tachycardia, secondary to Wolff-
Parkinson-White syndrome. He further noted that an
electrophysiological study had shown supraventricular
tachycardia. The study “goes along with” the diagnosis of
Wolff-Parkinson-White syndrome, he indicated.
A June 1996 clinical record from Garry Cole, D.O., notes the
veteran’s report of episodes of palpitations occurring once
per week. These episodes were unrelated to exercise, but
were associated with shortness of breath and chest pain,
lasting three to four minutes and resolving spontaneously.
They would last from three to four minutes and occurred about
once per week. The physician opined that the episodic
palpitations were probably related to the intermittent Wolff-
Parkinson-White syndrome. He was also diagnosed with
atypical chest pain that was considered not to be ischemic in
nature.
A January 1997 VA examination report indicates that the
veteran had had normal electrocardiograms in the past, as he
did on the present examination, but that this did not
preclude the diagnosis of Wolff-Parkinson-White syndrome.
The veteran was likely to have “significant difficulty”,
the physician opined, in the future, related to Wolff-
Parkinson-White syndrome and recurrent supraventricular
tachycardia.
A June 1997 emergency room note from St. Joseph Community
Hospital notes that the veteran had a sudden onset of sharp
chest and left lateral thoracic pain, etiology uncertain,
possibly referred pain from the bowel versus chest wall pain.
There was no sign of cardiac involvement at that time. The
history of Wolff-Parkinson-White syndrome was noted.
The veteran was examined by the VA in July 1997. The veteran
complained of chest pains that occurred two to three times
per day, usually lasting a few minutes, but up to all day in
duration. They produced some lightheadedness and a sensation
of irregular heart beats. The veteran’s electrocardiogram
showed a sinus bradycardia with some sinus arrhythmia, but
was otherwise unremarkable. The veteran was diagnosed with
Wolff-Parkinson-White syndrome with continuing symptoms of
chest pain and reduced cardiac output. The examiner noted
that the chest pain he began experiencing in the 1960s could
be associated with his Wolff-Parkinson-White syndrome or with
his hypertension, , but indicated that this was uncertain.
An August 1997 VA clinical record indicates that the veteran
had complained of chest pain, lightheadedness and a fast
heart rate. It was stated that there was no documented
evidence of arrhythmia as the etiology of the veteran’s
symptoms.
The veteran was examined by the VA in October 1997.
Electrocardiogram findings in the claims file showed left
atrial enlargement, but no other abnormal changes of
ischemia. A previous Holter monitoring was noted to have
been negative, as was a stress test from earlier in 1997.
The examiner stated that the veteran had chronic, recurrent
left-side chest pains. At the present time, although not
very clear to the examiner, “according to the files” this
was [apparently] related to hypertension or Wolff-Parkinson-
White syndrome. The examiner also noted the veteran’s
hypertension and indicated that there was no evidence of
coronary disease.
The veteran was hospitalized at St. Joseph Hospital in March
1998 with complaints of chest pain. A physical evaluation
revealed chest wall pain, left chest, “more
musculoskeletal.” The examining physician stated that he
did not see any sign of cardiac involvement. At discharge,
he was assessed with chest pain, secondary to chest wall
irritation, spasm or pinching.
At a May 1998 video hearing before the Board, the veteran
indicated that surgery had been considered with respect to
his Wolff-Parkinson-White syndrome. He discussed how he
would be short of breath, apparently due to Wolff-Parkinson-
White syndrome, when the weather was warm. He asserted he
had not been hired for several jobs because of Wolff-
Parkinson-White syndrome and his high blood pressure.
II. Rating of Wolff-Parkinson-White syndrome
During the pendency of this appeal, the regulations
pertaining to the evaluations assigned to cardiovascular
disabilities, such as the veteran’s Wolff-Parkinson-White
syndrome, were amended. 62 Fed. Reg. 65,207-224 (1997)
(effective January 12, 1998). Since the regulations changed
during this time period, the veteran is generally entitled to
have whichever set of regulations applied, former or current,
which provide him with a higher rating. Karnas v. Derwinski,
1 Vet. App. 308 (1991); Dudnick v. Brown, 10 Vet. App. 79
(1997). The Board notes that the RO has properly considered
the veteran’s Wolff-Parkinson-White syndrome under both the
new and former sets of rating criteria.
Disability evaluations are based upon the average impairment
of earning capacity resulting from a disability. 38 U.S.C.A.
§ 1155. The veteran’s Wolff-Parkinson-White syndrome had
been evaluated under the former rating criteria analogously
to paroxysmal tachycardia under 38 C.F.R. § Part 4,
Diagnostic Code 7099-7013, and was considered to be 10
percent disabling. See 38 C.F.R. § 4.20 (permitting
analogous ratings for diseases not listed in the Schedule for
Rating Disabilities, 38 C.F.R. § Part 4); see also 38 C.F.R.
§ 4.27, (the diagnostic code for analogously rated
disabilities is “built-up” with the first two digits from
the part of the schedule that most closely identifies the
part, or system involved, and the last two digits being
assigned as “99”).
This 10 percent evaluation under the former Diagnostic Code
7099-7013 contemplates infrequent attacks. In order to be
entitled to a higher evaluation under that diagnostic code,
which is the highest rating of 30 percent, the veteran must
demonstrate that he has severe, frequent attacks.
The key question here is whether the veteran’s frequent chest
pain attacks are manifestations of his Wolff-Parkinson-White
syndrome. If they are, he has credibly asserted--and has had
documented--numerous such attacks and would be entitled to an
increased rating under the former diagnostic criteria. If
the well-documented chest pains, however, are unrelated to a
service-connected disability, then the evidence is otherwise
largely negative for recent findings of Wolff-Parkinson-White
syndrome and he would not be entitled to an increased
evaluation for that condition.
On the particular facts of this case, it is apparent that an
increased rating is warranted. The veteran’s chest pains,
while often described as atypical or non-cardiac in nature
have also, quite often, been described in cardiac terms as
well. He has occasionally, although not always, responded to
nitroglycerin for his chest pains. Although his Wolff-
Parkinson-White syndrome is not always readily apparent when
he has been treated for chest pains, the record makes it
clear that Wolff-Parkinson-White syndrome can exist without
necessarily being demonstrated upon every medical evaluation.
The June 1996 evaluation of Prasad R. Palakurthy, M.D.,
relates palpitations and irregular heart rhythm
(supraventricular tachycardia) to Wolff-Parkinson-White
syndrome. That same month, Garry Cole, D.O., related the
palpitations and chest pain to Wolff-Parkinson-White syndrome
as well. The 1997 VA examination reports do not rule out
such an association, and another examination that year also
appears to make an association between chest pain and Wolff-
Parkinson-White syndrome.
This evidence is approximately in equipoise--as to whether
the veteran’s chest pain is related to his service-connected
Wolff-Parkinson-White syndrome--and the Board finds that he
is entitled to the benefit of the doubt on this question.
Since the Board finds that the veteran is entitled to have
his chest pain considered to be part of this service-
connected disability, the remaining question regards the
frequency and severity of attacks. The veteran has had
periods where he reported attacks more than once per day, and
has asserted having many attacks over the years. He has had
many hospitalizations for chest pain. That indicates that
his complaints were taken seriously. The Board thus finds
that, while there is evidence to the contrary, the veteran
most closely approximates the criteria for a 30 percent
evaluation under the former Diagnostic Code 7099-7013.
Under the recently revised evaluation criteria for
cardiovascular diseases, Diagnostic Code 7013 has been
eliminated, but supraventricular arrhythmias--the most
closely related conditions to the veteran’s service-connected
Wolff-Parkinson-White syndrome--are rated under Diagnostic
Code 7010. The highest evaluation under the new Diagnostic
Code 7010 is 30 percent, and thus a higher rating cannot be
awarded under the new regulations. Therefore, the Board need
not consider the application of the new criteria--the highest
applicable rating has already been awarded under the former
regulations. Karnas; Dudnick.
In reaching its decision, the Board has considered the
complete history of the veteran’s Wolff-Parkinson-White
syndrome as well as the current clinical manifestations and
the effect the condition may have on the earning capacity of
the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.10. The criteria for
an evaluation greater than that assigned have not been met or
approximated as explained above. 38 C.F.R. § 4.7. The
benefit of the doubt has been resolved in the veteran’s
favor. 38 U.S.C.A. § 5107.
ORDER
Entitlement to a 30 percent evaluation for Wolff-Parkinson-
White syndrome is granted, subject to the laws and
regulations governing the payment of monetary benefits.
REMAND
The veteran’s right hand scars were examined by the VA in
July 1997. The examination report, however, did not discuss
whether the scars were poorly nourished, whether they had
repeated ulceration, or whether they were tender and painful
on objective demonstration. See 38 C.F.R. § Part 4,
Diagnostic Codes 7803, 7804. Such considerations must be
addressed so that the Board can consider all potentially
applicable diagnostic criteria. See Green v. Derwinski, 1
Vet. App. 121, 123 (1991); Lineberger v. Brown, 5 Vet. App.
367, 369 (1993); Waddell v. Brown, 5 Vet. App. 454 (1993);
Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991).
To ensure that the VA has met its duty to assist the veteran
in developing the facts pertinent to the claim, the case is
REMANDED to the RO for the following development:
1. The veteran should be requested to
provide the names, addresses, and
approximate dates of treatment of any VA
and non-VA health care providers who have
treated him for the scars or claimed
neurological problems since December
1997. After securing any necessary
releases, the RO should obtain these
records and associate them with the
claims folder.
2. The RO should schedule the veteran
for a VA dermatological examination to
determine the extent and severity of his
right hand scars. All necessary tests
should be conducted and all findings
reported in detail. The claims file
should be reviewed prior to the
examination, and the examination report
should reflect that such a review was
made. The examiner is requested to
proffer an opinion as to whether the
scars are poorly nourished, whether they
have repeated ulceration or are tender
and painful on objective demonstration.
Prior to the examination, the RO must
inform the veteran, in writing, of all
consequences of his failure to report for
the examination in order that he may make
an informed decision regarding his
participation therein.
3. After the foregoing has been
completed to the extent possible, the RO
should readjudicate the remaining claims
upon appeal. If any benefit on appeal
remains denied, the RO should provide the
veteran and his representative a
supplemental statement of the case and an
opportunity to respond thereto.
Thereafter, the case should be returned to the Board, if in
order. The Board intimates no opinion as to the ultimate
outcome of this case. The veteran need take no action until
otherwise notified.
ROBERT D. PHILIPP
Member, Board of Veterans’ Appeals
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1998), a decision of the Board of Veterans’
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans’ Judicial Review Act, Pub.
L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date
that appears on the face of this decision constitutes the
date of mailing and the copy of this decision that you have
received is your notice of the action taken on your appeal by
the Board of Veterans’ Appeals. Appellate rights do not
attach to those issues addressed in the remand portion of the
Board’s decision, because a remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1997).
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